Citation NR: 9601738
Decision Date: 01/30/96 Archive Date: 02/09/96
DOCKET NO. 91-45 289 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in San Juan,
Puerto Rico
THE ISSUE
Whether new and material evidence has been submitted to
reopen the appellant’s claim for service connection for a
psychiatric disorder, diagnosed as schizophrenia.
REPRESENTATION
Appellant represented by: Puerto Rico Public Advocate
for Veterans Affairs
WITNESSES AT HEARING ON APPEAL
The appellant and Raul Correa-Grau, M.D.
ATTORNEY FOR THE BOARD
Bernard T. DoMinh, Associate Counsel
INTRODUCTION
The appellant served on active duty for training (ACDUTRA)
from May 1977 to September 1977.
This matter comes to the Board of Veterans' Appeals (Board)
on appeal from a March 1991 rating decision by the San Juan,
Puerto Rico, Regional Office (RO) of the Department of
Veterans Affairs (VA), which denied the appellant's
application to reopen his claim for service connection for a
psychiatric disorder.
REMAND
The appellant is not a “veteran” because he served on active
duty for training only, 38 C.F.R. §§ 3.1(d), 3.6 (1994).
The appellant filed a claim for service connection for an
acquired psychiatric disorder, which was initially denied by
the RO in January 1981. The appellant timely appealed this
determination, and was denied service connection for a
psychosis in a September 1984 Board decision which became
final.
In the years between 1984 and the time of this appeal, the
appellant submitted various private and VA medical records to
support applications to reopen his claim. These records show
that he received outpatient treatment or hospitalization for
various medical problems, including a psychiatric disorder
which was always diagnosed as a form of schizophrenia.
However, none of them were considered to be new and material
evidence, and his applications to reopen his claim were
denied.
In the course of the appeal of the March 1991 RO decision,
which denied his current application to reopen his claim, the
appellant submitted a private psychiatric evaluation report
dated in June 1994 from his private psychiatrist, Raul
Correa-Grau, M.D. The report indicates that Dr. Correa-Grau
had reviewed records of the appellant’s prior medical
history, beginning in 1976, and had examined the appellant in
June 1994. In his report, Dr. Correa-Grau noted that the
appellant, who spoke only Spanish and no English, tended to
isolate himself during his period of ACDUTRA in 1977 because
he was unable to communicate with his superiors. The
psychiatrist noted that this caused the appellant to be
placed in a “minus reactionary resistance” situation, which
constituted a stressor for him. Dr. Correa-Grau diagnosed
the appellant with an undifferentiated type schizophrenic
reaction, and PTSD as a secondary element to be taken into
account. In his commentary, Dr. Correa-Grau remarked that
while the appellant was in Germany on ACDUTRA, he was
assigned to a unit with whom he was unable to communicate,
and that as a result of this he was harassed and humiliated
by his comrades. Dr. Correa-Grau opined that the appellant
felt isolated and entered into a state of acute sensorial
deprivation which tested his psychological resources and
capacity, and that this was the beginning of a latent
schizophrenia with symptoms of inferiority.
The Board is of the opinion that Dr. Correa-Grau’s 1994
medical report is evidence which is new and material to the
appellant’s claim for service connection for an acquired
psychiatric disorder. Dr. Correa-Grau directly attributed
the appellant’s psychiatric problems to his exposure to
psychological stress incurred during active duty for
training, with onset of schizophrenia during this period.
This gives rise to a reasonable possibility of a change in
the prior adverse Board decision of 1984. On the basis of
this new evidence, the Board finds that the appellant’s claim
should be reopened for a de novo review of the merits of his
case. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156
(1994); Colvin v. Derwinski, 1 Vet.App. 171 (1991); Cox v.
Brown, 5 Vet.App. 95 (1993).
However, the Board finds that a remand for additional
development of this claim is necessary before it may be
reviewed. Any additional, recent medical records which are
relevant to the appellant’s claim must be obtained and
associated with his claims folder. Thereafter, a VA
psychiatric evaluation of the appellant should be conducted,
in which the merits of Dr. Correa-Grau’s psychiatric opinion
should be addressed. 38 U.S.C.A. § 5107(a) (West 1991);
38 C.F.R. §§ 3.103(a), 19.9 (1994); Littke v. Derwinski, 1
Vet.App. 90 (1990); Murincsak v. Derwinski, 2 Vet.App. 363,
371 (1992).
In view of the foregoing, the case is REMANDED to the RO for
the following development:
1. The RO should contact the appellant
and request that he provide them with a
list of all his medical care providers,
both VA and private, who treated him for
a psychiatric disorder since Dr. Correa-
Grau’s evaluation in June 1994. This
cut-off date will allow the RO to obtain
the most recent, relevant records of
psychiatric treatment showing the
appellant’s current mental condition,
while minimizing the inclusion of
irrelevant evidence or duplicates of
previously-obtained evidence in the
claims folder. After this list has been
provided, the RO should contact the
medical care providers and obtain these
records in accordance with the provisions
of 38 C.F.R. § 3.159 (1994).
2. After the above actions have been
completed, and all the relevant medical
evidence has been associated with his
claims folder, the RO should provide the
appellant with a VA psychiatric
evaluation. The claims folder must be
reviewed prior to the examination, and
the discussion in the evaluation report
should reflect that Dr. Correa-Grau’s
1994 diagnoses and opinions as to the
type, etiology, and time of onset of the
appellant’s psychiatric disorder were
considered. The diagnostic criteria of
the 3rd edition of the Diagnostic and
Statistical Manual of the American
Psychiatric Association (DSM-III) must be
applied in this diagnosis. It should be
noted that this VA psychiatric evaluation
report is not limited to discussing only
Dr. Correa-Grau’s psychiatric
conclusions, and discussion of other
medical records associated with the
claims folder may be included.
Thereafter, the RO should review the claim de novo. If the
claim is denied, the appellant and his representative should
be issued a supplemental statement of the case and given an
opportunity to respond. Then the case should be returned to
the Board.
J. E. DAY
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1994).
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